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REVIEW

CURRENT OPINION Teen prevention: current perspectives

Claudia Lavina and Joanne E. Coxb,c

Purpose of review Teen pregnancy has been subject of public concern for many years. In the United States, despite nearly 2 decades of declining teen pregnancy and birth rates, the problem persists, with significant disparities present across racial groups and in state-specific rates. This review examines recent trends, pregnancy prevention initiatives and policies that address the special needs of vulnerable youth. Recent findings Unintended teen impose potentially serious social and health burdens on teen and their children, as well as costs to society. Trends in teen pregnancy and birth rates show continued decline, but state and racial disparities have widened. Demographic factors and policy changes have contributed to these disparities. Research supports comprehensive pregnancy prevention initiatives that are multifaceted and promote consistent and correct use of effective methods of contraception for youth at risk of becoming pregnant. Summary There is strong consensus that effective teen pregnancy prevention strategies should be multifaceted, focusing on delay of sexual activity especially in younger teens while promoting consistent and correct use of effective methods of contraception for those youth who are or plan to be sexually active. There is a need for further research to identify effective interventions for vulnerable populations. Keywords adolescent, pregnancy prevention, teen birth rates, teen pregnancy rates

INTRODUCTION FRAMING THE ISSUE Most teen pregnancies in the United States are The US teen pregnancy rate continues to be one of unplanned and unintended and have far reaching the highest in the developed world – more than consequences [1]. Teen mothers are at high risk twice the rates in Canada (28 per 1000 women aged for school failure, low self-esteem and depression 15–19) and Sweden (31 per 1000) [11]. Although the [1–3,4&]. Mothers younger than 17 years of age are teen pregnancy rates increased in 2006 and 2007, in at higher risk for premature births, low infant birth 2008, the US teen pregnancy rate reached its lowest weights, in the first year of life and point in more than 30 years (67.8 per 1000 women child abuse. The children of teen mothers are more aged 15–19 years old) down 42% from its peak in likely to perform poorly in school and engage in 1990 (116.9 per 1000) [11]. Similarly, the US overall high-risk behaviors in and are less adolescent reached a nadir of 39.1 per likely to be economically successful as adults 1000 women aged 15–19 in 2009 [12]. That year, [2,5–9]. approximately 750 000 women younger than 20 Adolescent results in loss of human became pregnant and 414 879 gave birth [13]. To potential. More than 75% of teen mothers receive understand the trends in teen pregnancy, we have to public assistance within 5 years of their child’s

birth [2]. Teen childbearing in the United States a b cost taxpayers $10.9 billion dollars in 2008 [10]. Harvard School of Public Health, Division of Adolescent/Young Adult and cDepartment of Pediatrics, Children’s Hospital Boston, Many biological and social factors have been Harvard Medical School, Boston, , USA associated with these poor outcomes, including Correspondence to Claudia Lavin, MD, Division of General Pediatrics, nutrition, (approximately two-thirds of Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, pregnant adolescent women already live below USA. Tel: +1 617 55 181; fax: +1 617 39 458; e-mail: claudialavin@ the level of poverty), social disorganization, poor hotmail.com access to and stigmatization Curr Opin Pediatr 2012, 24:462–469 [1,6,9]. DOI:10.1097/MOP.0b013e3283555bee

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to reduced sexual activity [20]. But the federal KEY POINTS mandate for funding abstinence-only programs Teen pregnancy rates in the United States continue to after 2002 and lack of comprehensive programs be the highest in the developed world, and significant that address contraceptive promotion and disparities exist between states and regions. use may contribute to states’ disparities in teen pregnancy rates [21&] and has been attributed to Programs that use a comprehensive approach and the recent increase in STIs, including the number include correct information about contraceptives in addition to promoting delay of sexual activity are more of young men infected with HIV [22]. Although effective than abstinence-only programs. other industrialized countries use abstinence in their programs, they also include contraceptive Age and culture of target populations should be use promotion and sexual programs [23]. considered when developing pregnancy prevention intervention. CURRENT TEEN PREGNANCY PREVENTION MODELS look at the factors that influence adolescent sexual Evaluating the effect of evidence-based teen behaviors and current demographic and govern- pregnancy prevention interventions is important ment policies. in order to frame national and state policies. Variables that affect teen pregnancy trends Multiple interventions have been developed over include shifts in the racial and ethnic composition the years to address teen pregnancy. The most of the population, with an increasing effective teen programs that incorporate evidence- population as a driving force for high teen birth based approaches can be placed into one of three rates [1,8,14]. There are long-standing disparities in categories: clinic-based interventions, school-based rates by race and by state. The overall prevalence of and school-linked interventions (community having ever had in 9th–12th programs). These interventions share common grade students is 65.2% for blacks, 49.1% for characteristics, including longer appointments and 42% for whites, as reported by the and individual counseling, educational programs, 2009 National Youth Risk Survey [15]. Yet, when confidential services, contraceptives (although, due controlling for other factors, poverty is strongly to policy funding barriers, many of the interven- associated with risk for teenage pregnancy tions do not specify whether contraceptives or pre- [1,6,16]. Teen birth rates also vary considerably by scriptions were offered on site), free-cost or low-cost state; in , 65.7 per 1000 women aged services, referrals and active outreach [24]. 15–19 years old gave birth in 2008 compared with The evaluations of most of these programs 19.8 per 1000 in [17]. From another focusing on sexual behaviors, HIV/STI and preg- perspective, the decline in teen birth rates from 1991 nancy prevention have been rigorously analyzed to 2006 was only 17% in Oklahoma compared with by The National Campaign to Prevent Teen Preg- 47% in [1]. The disparities can be large nancy. The 2010 ‘What Works’ report reviewed enough that some of the birth rates in southern evidence-based experimental designs that are effec- states of the United States compare to levels in some tive in preventing teen pregnancy and STIs [24]. In developing countries [18]. 2002, the CDC’s Division of To examine this issue, a prospective cohort funded the national project, promoting science- study examined teen birth rates in 24 states for based approaches in teen HIV and STI prevention 15–17 years old from 1997 through 2005 and found with the goal to decrease STI and HIV rates and teen significant evidence that increased sexuality edu- pregnancy [25]. Curriculums for these programs are cation within school was associated with lower birth available at the ETR associates website [24] and the rates. However, when controlling for demographic CDC’s Reproductive Health website [25]. Some of characteristics, religiosity and laws, states these programs are difficult to replicate and expens- with greater conservatism and religiosity had sig- ive, or may not work outside the setting in which nificantly higher teen birth rates despite sexuality they were implemented. However, other programs education curriculums [19&&]. Possible explanations are less expensive and easy to implement. Never- of these findings are public policies related to access theless, due to funding restrictive policies, many did to contraception, abortion and sexual education. not measure their effects on teen pregnancy, Recent research concluded that a significant decline although they reported significant positive effects in pregnancy rates between 1995 and 2002 among on sexual behaviors, such as increased condom use, 15–19-year-olds was mainly attributed to an use of contraceptives and decreased number of increase in contraceptive use and, to a lesser extent, partners. For the purpose of this review, we will

1040-8703 ß 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins www.co-pediatrics.com 463 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. HIV " [28] et al. schools, results were modestshort and term. Pregnancy rates:statistically no significant differences between intervention vs. controls. 25% lost at f/uand (jail lack time, of address) community settings significant effects of comprehensive interventions on HIV/STD-related behaviors. Pregnancy prevention NM. The abstinence programnot did meet the Federalabstinence criteria programs for and didcriticize not the use of schools. Initiation delay NM knowledge and vulnerability, and safer sex. Pregnancy andinitiation delay NM. Mueller started a pilot program in Denver evidence strongest in LatinoPregnancy teens. rates NM response to the Healthy2010 People objectives. Pregnancy rates NM Study performed in alternative high Program performed in low-income The middle school-based study found After school program in urban high Culturally based school program School-based program, showed School-based program developed in use with steady andpartners nonsteady and decreased frequency of sex atEffects 6 did months. not hold18 at months 12 and significantly more likely to remain abstinent and more likely to use condomswith compared the WI groupbetter (control) than and the standardcommunity AIDS intervention group significantly reduced sexual initiation, but no significant changes in other sexual behaviors, compared with other groups or control significantly reported more condom use, decreased frequency of sex partners, decreased pregnancy rates at 6 months f/u only,STD decreased incidence of partners and frequencysex of and increased condomconsistently, use compared with controls initiated sex vs. 30%control in group. the Significantly, increase in condom knowledge and use, STIs knowledgeself-efficacy and to refuse sexcontrols vs. sexuality expectations (such as ) and perceived susceptibility. Significant changes of personal sexuality expectations and parental communication vs. controls 18 months Significant increase of condom 18 months Teens in the CLI group were 24 months The abstinence-only intervention 12 months Significantly reduced the number 24 months Twenty-three percent of teens 6 months No significant differences on sessions two f/u sessions. Community intervention had four program activities, two events and 90-min workshop two sessions or 12 1-h modules over three sessions discussions, role play, video, interactive games and skill-building activities used group based, individual computer activities sessions Intervention Follow-up Results Comments Fourteen 26 total-hour Two 3-h workshops with Eight 1-h modules during Four 4-h sessions 12 months Girls in the intervention group Twelve 45-min lessons, Eight weekly 45-min 134 ¼ 428, n ¼ n 131, ¼ 392, WI n 134, safer sex 129, abstinence only 134, control 352 ¼ ¼ ¼ ¼ ¼ n intervention 391 long comprehensive short n n n AIDS standard community education n intervention 251 intervention 349 intervention 633 N Control 597, Comprehensive intervention CLI Control 271, Total 553 Six 1-h modules, group Control 558, Control 221, AA mixed, urban urban Hispanic, urban AA and Hispanic, urban urban mixed, urban F and M, grades 6–7, F and M, 12–17 yo, F and M, grades 8–11, F and M, grades 7–8, F, grade 7, mixed, F and M, 14–18 yo, study pregnancy prevention pregnancy prevention pregnancy prevention violence, self-esteem pregnancy prevention 2010 RCT, abstinence-only 2005 RCT, STD/HIV, 2004 RCT, HIV F, high school, AA, 2006 RCT, STD/HIV and 2010 RCT, STD/HIV and 2011 RCT, STD/HIV, pregnancy, 2006 RCT, STD/HIV and [27] [32] [26] [30] [31] et al. et al. et al. et al. [33] ‘SiHLE’ et al. et al. ‘Theory-Based Abstinence-Only Program’ ’Teen Health Project’ et al. ‘Cuidate!’ [29] ‘It’s Your Game. Keep It Real’ ‘Smart Girls Way’ ‘All4You!’ Table 1. Teen Pregnancy Prevention Programs ReferencePrograms focusing on sexual factors Jemmott Year Study type Population Sikkema DiClemente Villarruel Tortolero Graves Coyle

464 www.co-pediatrics.com Volume 24 Number 4 August 2012 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Teen pregnancy prevention: current perspectives Lavin and Cox significant financial and staff resources. Men did notsexual change behaviors significantly program for adolescent girlshigh at risk of pregnancy.leadership Peer model included. Pregnancy rates NM girls in the juvenileplaced system in out of home care program goal is theof improvement knowledge, attitudes and behaviors of teenagers regarding preconception, encouraged use of condoms, useplanning of methods family including abstinence and avoidance of multiple partners Pregnancy and frequency of sex NM school-based program. The results indicate the curriculum may promote greater condom use and contraception among sexually active men programs. Teens with fathers. Pregnancy rates NM This after school program requires Clinic-based, multicomponent Case management program for Community Program. The main Performed in clinic setting. This is a cohort of the Wise Guys Boys and girls after school 0.01) and 27% < P were significantly less likelyhave to had sex andpregnant become (by half), andlikely more to use dualcontraception methods (including of condoms) condoms and contraception than controls. Better stress management skills and social connectedness with school and family 2.4 times more likelypregnant to than become girls ingroup MTFC ( became pregnant in thegroup MTFC compared with 47% in the control group pregnancy in the catchment area was 60 andthan 80% the greater reduction atand the state county level, respectively. No success in repeatlevels pregnancy of new and recurrentinfections chlamydia and increased condom use, compared with controls and f/u knowledge ofreproductive sex, biology, STD transmission and attitudes toward sex and appropriate behavior in sexual relationships group reported ever havingwithout sex a condom compared with 60% in theFathers control were group. more likelyabout to sex-related talk topics with their sons Significantly more consistent use of The decline in primary teen Significantly reduced the number ment ; NM, not measured; RCT, randomized controlled trial; interim study a decade last call approximately 3 years Girls in the intervention group 12-month 24 months Girls in control group were Trend over 3 months after 6 months Significantly greater post 3-h each day activities SCT, resilience paradigm through case management and peer leaders. Monthly visits parents, daily phone calls, weekly support meetings monthly basis. Preconception and interconception care, youth developmental skills provided 15-min phone calls for 9 months and f/u 6 months.false True/ or five-point Likert scale items. Curriculum delivered 8–10 weekly 45-min sessions Intervention Follow-up Results Comments 5 days a week for Intervention included MTFC and trained foster 4–5-h session on a Two 4-h sessions and four Questionnaires, pre/post 14-h contact 12 months Thirty-one percent of intervention intervention 600 control 127 intervention 81 intervention, county 12 589 and state 190 397 as comparisons intervention 348 intervention 124 intervention 277 N Control 600, Intervention 125, Control 85, Total 3155 community Control 367, Control 106, Control 277, AA and Hispanic, urban urban urban AA, urban urban urban urban F and M, 13–15 yo, F, 13–17 yo, mixed, F, 13–17 yo, mixed, F and M, 10–19 yo, M, grade 7, mixed, youth development program prevention prevention primary and repeat pregnancy attitudes (including violence), STD ) 2002 RCT, pregnancy and 2010 RCT, pregnancy 1998–2007 Ecologic study, on 2009 RCT, STD/HIV F, 15–21 yo, AA, 2011 RCT, sex knowledge and 2007 RCT, STD/HIV M, 11–14 yo, AA, ] & Continued [40] Federal . [39 [34] 2009 RCT, pregnancy et al. [35] et al et al. et al. et al. ‘Children’s Aid Society (CAS)-Carrera’ [38] ‘‘Prime Time’ Healthy Start Program, ‘Prime Time’ et al. ‘HORIZONS HIV’ Brown [36] ‘Wise Guys Male Responsibility Curriculum’ [37] ‘REAL Men’ Table 1 ( ReferenceKerr Year Study type Population Programs focusing on both sexualCarrera and nonsexual factors (includes youth development programs) Sieving Salihu DiClemente Gruchow and Dilorio AA, African American; CLI,SCT, community social level cognitive intervention; theory; F, WI, ; workshop f/u, intervention. follow up; LSK, life skills program; M, male; MTFC, multidimensional treat

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include only the most recent or up-to-date studies. Comprehensive education programs Table 1 [26–38,39&,40] summarizes programs by Sexuality and HIV education programs that include type, design, strength of evidence and outcomes. discussion of condoms and contraception do not increase sexual intercourse and do not increase the number of sexual partners. In fact, there is evidence COMPREHENSIVE REVIEW OF that they decrease the number of partners. HIV EVIDENCE-BASED PROGRAMS programs that included sexual education had a Strategies used in evidence-based programs vary. positive impact on sexual behavior for up to 31 Some use an abstinence-only approach with no dis- months [9]. In school-based models, providing con- cussion of contraception. Comprehensive programs traceptives and condoms did not hasten the onset of focus on educating teens about healthy relationships, sexual intercourse or increase its frequency. These and contraception. Multicomponent pro- programs also increase the opportunity for one-on- grams often recommend abstinence as one approach one counseling and aim to delay initiation of sex but include information about contraception. using abstinence prevention techniques [9]. Programs that fall in this category are very diverse. Examples of the most up-to-date evi- Abstinence programs dence-based programs are as follows: school-based The US government, through the Adolescent Family programs: all are comprehensive RCTs, and, even Life Act, Community Based Abstinence Education, though most of them showed increases in condom Title V and reform, supported abstinence use and other safer sex practices, pregnancy rates only as a teen pregnancy reduction strategy with were not measured. Examples are ‘Cuidate!’ [27], delay of sexual activity until . Under 2002 ‘It’s Your Game. Keep It Real’ [29], ‘Smart Girls federal funding regulations, abstinence policies Way’ [30] and ‘All4You!’ [31]. Community programs became so restrictive that most of these programs that have experimental designs include ‘Teen could not include information about contraception Health Project’ [32], ‘Keepin’It R.E.A.L’ (Dilorio or safe sex practices [20]. The most recent national et al., unpublished observation) and ‘SiHLE’ [33]. data (2005) shows the diversity of abstinence-only Again pregnancy rates were not measured; however, programs, and recent evidence suggests that absti- condom use increased significantly compared with nence-only education is positively correlated with controls and the number of partners at follow-up increased teenage pregnancy, birth rates and STIs, decreased. In a program for very high-risk teens out even when adjusting for socioeconomic status, edu- of the juvenile system, Kerr et al. [34] used an intense cational attainment, race and family planning serv- multidimensional treatment foster care (MTFC). ices [19&&,20,21&,22,41]. In 2008, the ‘Labor,Health Women in the control group were 2.5 more likely and Human Services, Education and Other Agencies’ to become pregnant than women in the MTFC bill provided 114 million dollars for new evidence- group. Clinic-based programs include ‘Horizons based teen prevention initiatives in 2010 [21&]. This HIV’, a RCT [35]. The study, based on social cogni- will provide opportunity for studying a wider range of tive theory and the theory of gender and power, did teen pregnancy prevention interventions. not measure pregnancy rates, but found signifi- An example of a well-developed randomized con- cantly higher rates of condom use and fewer trolled trial (RCT) on abstinence-only intervention chlamydial infections. Despite progress in the is the ‘Efficacy of a Theory-Based Abstinence-Only experimental quality of the majority of these inter- Intervention Over 24 Months’ by Jemmott et al. [26]. ventions, there is still need for more rigorous The study was performed in an urban public school of research with wider reporting of results and demon- predominantly African–American students in grades stration of reproducible results [9]. 6 and 7. The self-reported outcomes showed a sig- Although men are often the initiators of teen nificant decrease in ever having sexual intercourse in sexual activity, most pregnancy prevention pro- the abstinence-only intervention compared with the grams target women. In this review, we found two school’s health promotion group over the 24-month current experimental design studies that address period. However, there were no differences in other pregnancy prevention in men. The first is ‘The Wise sexual behaviors, such as condom use or multiple Guys Male Responsibility Curriculum’ [36] and the partners [26]. One of the limitations of this study is second ‘REAL Men’ [37]. The former demonstrated that a 24-month follow-up was relatively short for significant increases in knowledge of sex, reproduc- middle school students with low baseline rates of tive biology and STD transmission with more desir- sexual activity, questioning how effective this pro- able attitudes toward sexual relationships and gram would be in maintaining abstinence for the promoted greater condom and contraceptive use long term. among participants. The latter involved fathers in

466 www.co-pediatrics.com Volume 24 Number 4 August 2012 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Teen pregnancy prevention: current perspectives Lavin and Cox the intervention, and results included significantly that targeted an underserved, African–American more use of condoms and an increase in fathers’ population aged 10–19 years. The intervention con- likeliness to talk about sex and related topics with sisted of offering , family planning, their sons. These programs are a great resource for drug and violence prevention and communication schools and parents and they have shown great and negotiation skills. Some of the participating educational outreach for this population. community organizations had interactive forums for youth to enhance physical, mental and pro- fessional development. Over a decade, primary teen Multicomponent programs pregnancy decreased by 27%, which was 60 and 80% These programs address motivation and skills build- better, respectively, than county and state rate ing along with comprehensive sexual education reductions. Efforts to reduce repeat pregnancy were programs. One of the most effective RCTs is the not statistically different among the community, ‘Children’s Aid Society (CAS) Carrera’ [38]. This is county and state levels. an extensive urban New York city intervention that In a recent meta-analysis, teen pregnancy inter- provides strong results showing a 50% decline in ventions that appear to be most effective include a teenage pregnancy, and increases in both condom multifaceted or multicomponent approach. Indivi- and contraceptive use through 3 years of follow-up. dual and clustered trial analysis of these inter- However, the program was only successful in ventions reports that the concurrent use of women, but had no significant impact on men’s multiple interventions such as education, skills sexual behavior. The CAS–Carrera curriculum has building, abstinence and contraception promotion been replicated partially in other states with little significantly reduces the risk of unintended teenage success, mostly because CAS program staff educators pregnancy [44]. were not utilized for training and not all parts of the program were implemented [42]. The program is expensive to implement and maintain. However, Other strategies in a recent economic evaluation of the CAS–Carrera A controversial strategy to prevent teen pregnancy program, the results showed that, whereas the includes programs with infant simulators targeting economic benefits of the short-term intervention teens’ perceptions of pregnancy and parenting using may seem to be overshadowed by the operating the model of virtual infant parenting classes. Most of costs, extrapolation analysis showed that the total the studies have shown mixed results. A majority benefit to society exceeded operating costs by on have small sample sizes and short follow-up inter- average $10 474.77 per adolescent per year by age 30 vals [45]. In 2012, the largest school-based RCT of [43]. this kind, with 1267 female participants and 1567 Another recent example is the ‘Prime Time’ matching controls, aged 13–15 years on entry, will study [39&]. Preliminary 12-month outcomes have be completed. Data through age 19 years will be been reported. This is a clinic program that includes obtained via data linkage to hospital medical female teens aged 13–17 years meeting specific records, abortion clinics and education records from high-risk criteria. The program uses case manage- 2003 to 2012. The study will evaluate the influence ment and peer leadership support. At 12 months, of infant simulators on teens’ behavior, reduction in the intervention group reported more consistent rates of teenage births, abortion rates, self-efficacy to use of condoms and/or hormonal contraception make informed decisions and increased knowledge compared with the control group. Other benefits of/or use of services relating to having a child and reported include better stress management skills and child and maternal outcomes, if any [46]. more social connectedness with school and family waivers for family planning have compared with controls, suggesting that youth funded access to contraceptives and have been development interventions along with sexual edu- shown to decrease the incidence of unplanned preg- cation and contraceptive promotion in a clinic nancy, especially in low-income women and teens setting are promising in preventing teen pregnancy [6,16,21&]. The cost of one Medicaid-covered birth in in high-risk youth. the United States, including prenatal care, delivery, Of publicly supported programs, the Healthy and infant care for the first year of Start Program is uniquely positioned in the com- life, was $12 613 in 2008. During the same year, the munity to address the needs of youth at risk of cost of contraception per client was $257. During becoming pregnant or repeat pregnancy. In Tampa, 2008, an estimated 1.9 billion dollars were spent in Florida, the Federal-Funded Healthy Start in public funding for family planning programs. The Hillsborough community developed the ‘REACHUP’ investment resulted in 7 billion dollars of savings for program [40] with community-based organizations Medicaid for the cost of unplanned pregnancies.

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